Provider Demographics
NPI:1265741201
Name:HISSAM, LAURA HAWKINS (DMD)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:HAWKINS
Last Name:HISSAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5420 PAULSEN STREET
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405
Mailing Address - Country:US
Mailing Address - Phone:912-777-5767
Mailing Address - Fax:912-777-5773
Practice Address - Street 1:5420 PAULSEN STREET
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405
Practice Address - Country:US
Practice Address - Phone:912-777-5767
Practice Address - Fax:912-777-5773
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0134331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice